This Angel is pissed off. I'm Nurse Anne and I work on large general medical ward in the NHS. These are the wards with the most issues surrounding nursing care. The problems are mostly down to intentional understaffing by hospital chiefs that result in a lack of real nurses on the wards.
"The martyr sacrifices themselves entirely in vain. Or rather not in vain, for they merely make the selfish more selfish, the lazy more lazy and the narrow more narrow"-Florence Nightengale

Friday, 28 January 2011

What it is like.

Back to the Medical Ward. Yay.

NOT.

My 13 hour night shift was due to end at 0700; at which time I have to be ready to give report to the oncoming Nurse.

Starting at 5AM I had to:

Start a magnesium infusion, give calcium gluconate and start an IVI with K then an addiphos infusion and take off a whole load of other doctors orders for a patient with deranged U+E's. The addiphos probably won't go up till day shift. He could have crashed at any moment with a K that low and I didn't want to leave him. He had bloods done over night and the results came back at 04:30. The doc wrote the new orders just afterward. I had to run around like a nut just to find some magnesium to start and of course document every aspect of all of this. All had to go through a central line. As you know this is time consuming.

I needed to get vital signs and obs on all 19 of my patients by 7 AM. If you wake the patients up before 6 to start getting all their obs they get angry. If I didn't start before 6 they would never got done and we would potentially miss the signs of a deteriorating patient.

I had to IV fluids on someone with renal failure. I had noticed his rubbish output at midnight but it took until 04:30 to get the doctor as he was the only doc on for multiple wards. Bloods hadn't been done for days on this patient and I needed to draw them.

I was also trying to keep the 02 on another patient, a confused patient who was desaturating without it and kept taking it off his face. He has disorientation secondary to sepsis so he could not understand me when I asked him to keep it on. He needed a mask rather than a nasal cannula.

At this time I also had to obtain,, mix, and administer 15 (yes fifteen) IV antibiotics for 8 patients that were prescribed them. This has to be done by 0800. Day shift starts at 0700 but doesn't even get out of handover until nearly 0800 so they can't do it. I had to do them and finish them by 07:30 AM.

I had 5 patients ask for controlled analgesia during this two hour window. This again is very time consuming. The system for obtaining and administering controlled drugs is a joke.

During this window I also had to be up to date on the current status of all my 19 patients. For example any little thing that changed with them on my shift I need to be onto right away. Examples of this include changes in observations, neuro observations. fluid balance, blood sugars etc. I had 5 diabetics. I need to act on every little thing and document it and it all needs to be done right now.
I had to act on the fact that I just noticed that my patient who is being treated for a UTI is completely unresponsive with a low BP. Had to call the doctor and wait for him to get around to calling me back. Fast IV fluids ordered as well as a million other things that needed to be done ASAP.
Two patients who needed IV antibiotics woke up and pulled their IV cannulas out. Two others pulled out their urinary catheters. It was like a blood bath for all 4.

I needed to monitor the patient on the IV insulin infusion closely. His blood glucose still isn't right. Something is wrong about this. Her consultant wanted her to stay on this infusion over the weekend. All night long I had told the house officer that the insulin infusion and the iv fluids that get hung with them were running out and that he needed to prescribe more so that I could hang more on the patient. The only time the doctor came was at 4:30 in the morning. I handed him the chart but he put it down and "forgot" to prescribe it before he got bleeped away somewhere else. Called him again and he said that he couldn't "come back to your ward" for awhile.

I had to deal with the fact that a patient woke up in agony with a blocked catheter. It needs irrigating. It was draining a few hours ago.

Remember all this is what got thrown my way between 5 AM and 7 AM. I was the only RN for double digit patients.

There were two lots of IV frusemide to give. 80mg. They need to be set through a pump. Got to watch those BPs because even though they are borderline (and I wouldn't give it if they were a smidge lower) these two chaps really need it.

I didn't want to leave the side of any one of these patients. But my god. Just standing in the treatment room mixing and preparing all these IV drugs is extremely time consuming.

I had to leave a few of the antibiotics for day shift. Day shift was so busy that they didn't give the 8AM meds that I didn't give until nearly noon.

I got a phone call at 0600 to take a direct admission from A+E as there are no beds anywhere else. The A&E nurse gave me report on my new patient. He is a drunk and combative alcohol patient who fell and hit his head. They want neuro obs every 15 minutes. He is sleepy but when he wakes up he knocks stuff over and hits. I didn't want to take this patient because the only empty bed I have is in a bay with 5 nice but frail confused elderly men. He will need a lot of admission stuff doing as soon as he gets to the ward i.e. paperwork to get his admission orders sorted.. The rest of the admission paperwork and all other legally required documentation I will knock out after my shift ends by staying over unpaid.

And that is just some of it. If I went into all the knowledge I have to have to manage those things we would be here all day. If I fucked any of that up just this much I could be held responsible for someone's death. Nurses are legally responsible for delivering the orders given by a doctor and monitoring patients. And my list reflects my doing just that.

That was my lot to carry and carry alone. I was the only qualified Nurse for those 19 20 patients There is no way that I can articulate on this blog how long it takes to prepare and mix and infuse and flush etc etc all those IV meds that were prescribed and due. It takes a lot of time away from the patients. Real hospitals have 24 hour pharmacies that make it their job to stay on top of new orders and mix and prepare and get to the Nurse these IV meds when they are do to be given. My NHS hospital DOES NOT have this. Even during the 9-5 hours that they are open they do not do that. They just develop more paperwork for the Nurses to fill in so that we can actually get the drugs and not get fired for a med error by omission (not giving a prescribed drug to a patient on time).

The only help I had was a teenage cadet called Beth. There was nothing in the above list that she could help me with. Nothing. She cannot even do observations/vital signs or check blood sugars. She is not a Health care assistant or a Nurse. I wish I had that lovely HCA from the surgical ward with me. He was mint. Beth refused to empty the catheters so that we could monitor an accurate fluid balance because "that's gross".

Between 5AM and 7AM this is what Beth had to do:

Change a few beds
Help people to the toilet.
Answer call lights and tell patients that the Nurse will be there as soon as possible. This confuses them since they think that she is a Nurse. She is wearing the same uniform as me after all.
Serve hot drinks at 7AM (she puts a trolley together and just blows past anyone who appears to be asleep rather than waking them up and encouraging fluids).

I would rather just do the drinks myself but....you have seen my list of jobs happening at this time.
If anyone pees or drinks she needs to measure it and write the value on the fluid balance chart. She didn't bother because she doesn't understand the point. As a matter of fact I asked her to do just that whilst my arms were loaded with IV meds, vital signs equipment, and new admission orders. She just rolled her eyes at me and said she was "too busy" because she was "serving drinks".Doctors and Nurses could kill a patient if they don't have an accurate fluid balance. Serving drinks took her all of 5 minutes since she ran past any patient who was sleeping or quiet. Then she sat at the station on her mobile.

Beth cannot help me with anything on my list as she is not a Nurse. But I must help her change those beds on top of everything else otherwise we get the cries of "those damn new fangled to posh to wash RN's leave all the real work to the care assistants". And I just don't want to fucking hear it.

And at 07:30 she will be out the door on her way home regardless of what is going on in that ward. She is not a Nurse, she is not licensed. What does she care? I will still be giving report. Giving report on 20 patients takes a long time. Who is looking out for my patients while I am handing over? Beth will be on the Bus. She doesn't understand what I have on my shoulders with those patients...she doesn't even understand what addiphos, deranged U+Es, hypoglycemia and sliding scale insulin means. She has no idea what a Nurse does she just sees me flying in and out of rooms. She tells the patients that she is a "real nurse" and a "nice nurse" because she is the one who serves them tea. And they suck it up. Most of what I am doing for them goes unseen by them.

Cadet Beth is real pissed off because she had to do the bed changes on her own mostly. She will piss and moan to anyone she who will listen about how she was left to do all the real work (8 out of 14 bed changes; I managed to assist with 6 of them) because the Nurse "wouldn't help her". The patients will tell her that she is the "nice nurse" who was kind enough to provide them with a drink and say "some others cannot be bothered with that because they think they are so high and mighty". And the patients will say this too Beth whilst looking daggers at me. They have absolutely no fucking clue what needs to be done to keep them alive and who is doing it.; They get that the doctors are the brains who prescribe treatment. And they get that nice nurses staff like Beth "care" enough to give them a drink. But they totally miss the knowledge bus on everything that is smack in between of that. The bus took off and the patients are still at the station.

Beth was on her way home at 07:30. I was still there on the ward tying up legally required loose ends at 9:30. They stopped paying me at 07:30. I think that without the new admission I may have made it out of there by 8:30 but nevermind. My daughter was late for school. Again.

Fuck this shit. I want a clipboard job. And when I leave I will be replaced with another cadet. And when that happens there will be one RN to 40 beds rather than one RN to 20 beds.

I love bedside Nursing but this is just too damn much. It isn't Nursing that is the problems it is the working conditions. The day shift nurse will be in for it. When the consultants come in and see that the fluid balance charts are blank from the night shift (thanks Beth, you worthless slut) they will smackdown on the Nurse who happens to be standing the closest to them.

Imagine how different things would have been if this was the scenario: Instead of just Beth and I for those 20 patients IMAGINE IF we had the recommended ratio of one nurse to 4 patients. Imagine if each of those 4 patients were sharing one Nurse rather than all 20 sharing one Nurse and one cadet? Imagine if each Nurse was able to do total care for her 4 patients......everything from dealing with IV infusions to changing their beds and encouraging a drink of tea.

I would stay in the job if that was the case. But it will never be the case here. NHS hospitals do not want to hire qualified Nurses to work at the bedside. They do not want to pay for that.

When I finally left the ward at 09:30 I was near tears. I was so rushed during those hours I was terrified that I made a mistake and killed somebody. I was afraid that maybe I hung the wrong meds on the wrong patients. I was afraid I missed somethingm like a low BP or a patient who had stopped fucking breathing. OMG I hope that patient finally kept his 02 mask on. I was afraid that one of the patients would go down to PALS and tell them about how I was the mean nurse who ran past them as they were shouting for help (I had to). Oh but that Beth, she was lovely and made us tea....

32 comments:

Much as I love Keanu, it was a poor adaptation of the comic :0(What a nerd I am!As for the rest, well- you couldn't make it up. Unfortunately even "real" hospitals with 24 hour pharmacies (like mine) still have laughable nurse to patient ratios on surgical wards, let alone medical.Problem I see is that the only way to get safe ratios will be to follow Oz...currently trying to do so by adopting a casemix approach...simply put, % of private care goes up and those needing public care get to wait and be last in the queue. If at all. Where does this leave most of the patients on the ICU, I wonder?

god I am having nightmares after reading that for it is that reason that I left nursing & became a train driver. But I sooo miss nursing. I will go back one day but if nothing changes I will be an HCA. Life is too short for all that stress.

I have been in her shoes. Getting smacked around by consultants who waltz onto the ward with no idea what is going on staffing wise. They start humiliating the Nurses in front of everyone because this and that isn't done.

How the hell am I supposed to make these cocky smart ass teenage ward assistants do anything? I certainly cannot physically keep on the fluid balances etc myself even though I want to.

If you say anything to these assistants, no matter how nice they go crying to management and say that they are being bullied and "stressed". Little witches don't know what stress is.

Anne , you articulate it so well, you remind me over again why I left ward nursing.

At least in A&E we have slightly better nurse/patient ratios, and mayhem like this occurs on only maybe 3 shifts out of every 6... instead of every shift.

I struggle to manage mentally/emotionally/physically when shifts like this happen, but I know there will be a lull in the madness, whereby I can look after people well, properly and how I wish my own loved ones to be looked after.

There is light at the end of the tunnel in A&E...ward nursing is getting worse...and its going to be getting much much worse.

They are teenagers mostly. The adult ones are called apprentices.They have no training before they start and are often left loose on a shift with no HCA showing them the ropes.

They think they know everything. The few HCAs that I work with are more fed up than we are. One of our very experienced HCAs tried to show one of the cadets how to do things properly and the girl just pulled faces. They are so young and there to learn blah blah blah.

The thing is this: shifts are getting staffed with 2 RNs and 2 cadets for an entire ward. On the rare occasion that we get an experienced HCA I am kissing her feet. Even though I am overwhelmed with the Nurse only stuff it still helps to have a smart, caring HCA I can trust.

When we try to talk to the cadets or get them disciplined we are told to stop dumping on the poor sweet litte (lowly paid so dont cost the trust money) darlings.

We have had a couple of them that have turned out to be very decent after a year or so and they are thinking about nursing school.

Its the reason I started working in the ICU in the first place...tired of being dumped on in A&E. Would I go back to a general ward? Hell, no. Friends who work in CCOT have stories (oh, so many stories) and the few days a month that I have to sort out the Pit (admissions) are more than enough contact.Yup, we get 24 hour pharmacy but they will only fill certain scripts. So, ICU and ED can have pretty much what we want but the rest of the world has to have only "emergency" stocks filled after 6pm. That said, the pharmacy techs do a pretty good job of making sure that the cupboards are well stocked in the first place, so running out of IV stuff is unlikely...and they can always mooch off ICU/ED if needed :0)As for the cadet situation...not sure what to suggest. We do not have them as yet, as our trainee HCAs have to be at least 17 (I believe) and most are older. There is a hospital training prog for HCAs and all are encouraged to do NVQ courses (although this years dates have yet to be announced-hmmmm). Do they still get paid a Band 2? Last time I looked this was the lowest salary band in my trust as Band 1 had been abolished by putting cleaning etc out to contract. Now cleaning is another story...:0(

This cadet business is beyond me. Surely teenagers would not apply for the job if they didn't have an interest in nursing in the first place, so why the attitude? And it's not their age because you can enter training at 17 1/2 or 18 and you don't get that kind of attitude from (most) students. So why do they think they're there??

I have a year to go Anne and I dont see the market improving. Alot of trusts ICU/HDU and A&E depts will not take newly qualifieds.

I will say that I am on a gen med warrd at the moment as a placement and it seems very well staffed and nowhere near as stressful as your ward. And in some ways seems less so than my old surgical ward.

That is good Student. If you can get into a well run and well staffed medical ward you will get a good start.

I have frequently been made aware that Scotland and Wales are much better than England in regards to staffing levels qualified and unqualified ratios etc.

The cadet thing. The hospital advertised for young people who were considering a career in Nursing. Many little chavettes who believe that Nursing is like holby city applied. It pays very slightly more than mcdonald's right?

Many of them do not stick around and the ones that do have a whole lot of attitude. They just don't have a clue.

I would not recommend ICU or ED as a first job for a newly qualified RN. Better to get the basics right on a general ward (med or surg, it doesn't matter which) and then maybe a year on admissions (especially if you are looking towards ED).I had also heard that staffing levels were better in scotland and wales. If you are able to be mobile then I would strongly suggest looking at several different trusts yourself to see what staffing levels are like- don't rely on the websites as these are propaganda tools. Whenever I have relocated, I have worked as an agency nurse to begin with in order to avoid being trapped in a crap trust-and the numbers of these seem to be growing :0(

Wales is better ratio-wise, but only just, and I don't why or for how long.

The trend I see in Wales is that there is a good balance of HCA's/RN's whereas in England it's top-heavy with HCA's each and every shift. Whatever the setting. Except for Outpatients, there is a fuckton of RN's in outpatients and very few HCA's, it is a dumping ground for Occupational Health.

So I imagine Wales will be at that point soon where HCA's will be over-run. Well so long as they are good HCA's and not these frightening cadets you keep speaking of, and so long as there are more RN's in the critical areas.

Hi, someone showed me this blog on Twitter. Nurse Anne - you are a bloody heroine to stay there. I would be screaming my head off within five minutes.

I've had a long term illness, I've never had to go to hospital for it, but it's the day I dread. So I just want to say thank you in advance for doing what you do under these ridiculous conditions. It's high time people realised what you amazing folks are being put through and exactly what is needed!

Hi Nurse Anne. I found your blog today and have been reading as many entries I can. It has brought me close to tears (I am a 29 yo male, not prone to weeping).

If I were you, I would have left ages ago - but then again, I'm not the kind of person who could be a nurse anyway. All I can say is that I wish you all the best, and hope you keep writing this blog.

It is such a shame that your compassion - something that makes you a great nurse - is being used against you. If you cared less, you would leave that hellhole, and your patients to fend for themselves.

Hypothetically, if nurses left their jobs en masse, do you think things would improve? Would it force the shit heads in charge to take notice?

Whoa, quite the eye opener.Will continue to follow your blog, and it's made me think twice about how I'll react should I ever unfortunately become a patient in a busy ward like this... People like you deserve more recognition. I find my job stressful, and sometimes I'm in charge of 2 dozen different jobs at one time, but I never have the fear of causing someone's death hanging over my head. Guess I should say thank you - without people like you, this country wouldn't function.

what a relief to read your post. I have linked it here. http://pressreform.blogspot.com/

I am involved in a mjor complaint to Press complaints commission over scandalous misreporting of Stafford Hospital - I am not a nurse - but I have seen immense harm done to our community by the use of some seriously dodgy statistical material that none of the journalists understood.

I wonder if you might like to help with this by writing to the PCC to let them know what impact this kind of reporting has?

In an atmosphere if universal deceit telling the truth is a revolutionary act. George Orwell.

Why has Nursing Care Deteriorated

Good nurses are failing every day to provide their patients with a decent standard of care. You want to know what has happened? Read this book and understand that similiar things have happened in the UK. Similiar causes, similiar consequences. And remember this. The failings in care have nothing to do with educated nurses or nurses who don't care. We need more well educated nurses on the wards rather than intentional short staffing by management.

About Me

I am a university educated registered nurse. We had a hell of a lot of hands on practice as well as our academic courses. The only people who say that you don't need a brain or an education to be an RN are the people who do not have any direct experience of nursing in acute care on today's wards. I have yet to meet a nurse who thinks that she is above providing basic care. I work with nurses who are completely unable to provide basic care due to ward conditions.
I have lived and worked in 3 countries and have seen more similarities than differences. I have been a qualified nurse for nearly 15 years. I never used to use foul language until working on the wards got to me. It's a mess everywhere, not just the NHS.
Hospital management is slashing the numbers of staff on the ward whilst filling us up with more patients than we can handle... patients who are increasingly frail. After an 8-14 hour shift without stopping once we have still barely scratched the surface of being able to do what we need to do for our patients.

Quotes of Interest. Education of Nurses.

Hospitals with higher proportions of baccalaureate-prepared nurses tended to have lower 30-day mortality rates. Our findings indicated that a 10% increase in the proportion of baccalaureate prepared nurses was associated with 9 fewer deaths for every 1,000 discharged patients."...Journal of advanced nursing 2007

THIS MEANS WE NEED WELL EDUCATED NURSES AT THE BEDSIDE NOT IN ADVANCED ROLES

Dr. Linda Aiken and her colleagues at the University of Pennsylvania identified a clear link between higher levels of nursing education and better patient outcomes. This extensive study found that surgical patients have a "substantial survival advantage" if treated in hospitals with higher proportions of nurses educated at the baccalaureate or higher degree level.

THIS MEANS WE NEED WELL EDUCATED NURSES AT THE BEDSIDE NOT IN ADVANCED ROLES

Dr. Linda Aiken and her colleagues at the University of Pennsylvania's Center for Health Outcomes and Policy Research found that patients experienced significantly lower mortality and failure to rescue rates in hospitals where more highly educated nurses are providing direct patient care.

Evidence shows that nursing education level is a factor in patient safety and quality of care. As cited in the report When Care Becomes a Burden released by the Milbank Memorial Fund in 2001, two separate studies conducted in 1996 - one by the state of New York and one by the state of Texas - clearly show that significantly higher levels of medication errors and procedural violations are committed by nurses prepared at the associate degree and diploma levels as compared with the baccalaureate level.

Registered Nurse Staffing Ratios

International Council of Nurses Fact Sheet:

In a given unit the optimal workload for a registered nurse was four patients. Increasing the workload to 6 resulted in patients being 14% more likely to die within 30 days of admission.

A workload of 8 patients versus 4 was associated with a 31% increase in mortality. (In the NHS RN's each have anywhere from 10-35 patients per RN. It doesn't need to be this way..Anne)

Registered Nurses in NHS hospitals usually have between 10 and 30+ patients each on general wards.

Earlier in the year, the New England Journal of Medicine published results from another study of similar genre reported by a different group of nurse researchers. In that paper, Needleman et al3 examined whether different levels of nurse staffing are related to a patient’s risk of developing complications or of dying. Data from more than 5 million medical patient discharges and more than 1.1 million surgical patient discharges from 799 hospitals in 11 different states revealed that patients receiving more care from RNs (compared to licensed practical nurses and nurses’ aides) and those receiving the most hours of care per day from RNs experienced fewer complications and lower mortality rates than those who received more of their care from licensed practical nurses and/or aides. Specifically for medical patients, those who received more hours per day of care from an RN and/or those who had a greater proportions of their care provided by RNs experienced statistically significant shorter length of stay and lower complication rates (urinary tract infections, gastrointestinal bleeding, pneumonia, cardiac arrest, or shock), as well as fewer deaths from these and other (sepsis, deep vein thrombosis) complications

•Lower levels of hospital registered nurse staffing are associated with more adverse outcomes such as Pneumonia, pressure sores and death.
•Patients have higher acuity, yet the skill levels of the nursing staff have declined as hospitals replace RN's with untrained carers.
•Higher acuity patients and the added responsibilities that come with them increase the registered nurse workload.
•Avoidable adverse outcomes such as pneumonia can raise treatment costs by up to $28,000.
•Hiring more RNs does not decrease profits. (Hospital bosses don't understand this. They think that they will save money by shedding real nurses in favour of carers and assistants. The damage done to the patients as a result of this costs more moneyi.e expensive deaths, complications,and lawsuits, and complaints....Anne)

Disclaimer

I know I swear too much. I am truly very sorry if you are offended. Please do not visit my blog if foul language upsets you. I want to help people. That is why I started this blog and that is why I became a Nurse. I won't run away from Nursing just yet. I want to stick around and make things better. I don't want the nurses caring for me when I am sick working in the same conditions that I am. Of course this is all just a figmant of my imagination anyway and I am not even in this reality. Or am I?Any opinions expressed in my posts are mine and mine alone and do not represent the viewpoint of the NHS, the RCN, God, or anyone else.